Visual Acuity

De Los Reyes, Maalim, Mandal, Sandoval

Group 5B
 Visual Acuity
• VA (Visual Acuity) = distance of patient from the chart/distance at
which normal eye can read the given line.
• Fundamental element of basic eye examination
• Performed initially before any other eye examination/manipulation
• Most basic types of vision are Distance and Near VA tests.
• Always test for both eyes, one at a time or separately.
• For toddlers & children, use pictures.
• Binocular visual acuity is useful for assessing functional vision such
as for assessing the eligibility to drive.
Notations Used in recording visual acuity
VA Visual acuity

OD Right eye (Oculus Dexter)

OS Left eye (Oculus Sinister)

OU Both eyes (Oculus Universali / Uterique)

sc Without correction / no correction

cc With correction

ph Pinhole

NV Normal vision
 Overview for taking VA
Purpose To correctly assess the patient’s far and near visual acuity for
both eyes

Resources ● Snellen / ETDRS / E Chart (Far Vision)

● Jaeger Chart (Near Vision)
● Occluder / Pinhole

Thing to watch out for ● Literacy

● Communication disability
● Notable Infection
● Position patient at a distance of 20 feet or 6 meters

Normal Findings ● 20/20 for both eyes for far vision without pinhole
● J1+ for both eyes for near vision
 Distance / far va
• Snellen chart at 20 feet OR 6 meters (Divergence)
• If there is Poorer eye, start with the worse eye from the biggest
letter up to the smallest readable letters.
(Why? So patient won’t be able to memorize the letters or symbols on
the chart)
• Check VA of the fellow eye; Do Pinhole testing for both eyes after
• Do VA with corrective lenses (If with correction, start without
glasses before with corrective lenses)
• Should be performed in all patients, including children for early
detection of amblyopia/ lazy eye.
 Steps
1. Ask the patient to stand or sit at a designated testing
distance (20 feet from a well illuminated Snellen chart or 4
meters from an ETDRS wall chart)
2. Examine the poorer eye first. If there is no poorer eye,
the right eye is examined first.
3. Ask the patient to make sure that the occluder is not
touching or pressing against the eye. Observe the patient
4. Ask the patient to say aloud each letter or number or
name the picture object on the lines of successively smaller
optotypes, from left to right until the patient correctly
identifies only half the optotypes on a line.
 Steps
5. Note the corresponding acuity measurement shown on that
line of the chart. Record the acuity value separately with
correction and without correction.

● If the patient missed half or fewer than half the

letters on the smallest readable line, record how many
letters were missed. (E.g. 20/40 -2)
● Conversely, if the patient reads the next line but
does not reach half the letters, record how many
letters were red in excess.(E.g. 20/40 +2)
 Steps
6. If the patient could not read the biggest optotype line,
have the patient come nearer until the patient can see the
biggest optotype line. Record the acuity value, reducing the
numerator by the distance the patient went nearer with (E.g.
15/200 if using a Snellen chart). Continue doing so until
the patient is 5 feet away from the Snellen chart.

7. If the patient still could not read the largest optotype

line 5 feet away, begin having the patient count the
examiners fingers 5 feet away from the patient. (Report: CF
at 5 feet)
 Steps
8. If the patient still could not see and count the
examiner's fingers, occlude the eye not being examined with
cotton or cloth to ensure that the eye not being examined is
fully and properly occluded. Have the examiner wave his or
her hand and ask if the patient could see the examiner's
hand movement. Vary the examination, alternating moving the
hand and keeping it still. Make sure that the examining hand
that is waving is not too close as for the patient to feel
its presence.
 Steps
9. If the patient still could not see the examiner's hand,
test the patient for Light Perception & Projection. To do
this, use a penlight and illuminate the eye being examined
and illuminate it from four different quadrants namely
superiorly, temporally, inferiorly, and nasally. Ask the
patient if he or she can identify the direction where the
light is coming from and record it accordingly. If the
patient can identify all four quadrants, record it as "good
light projection". If the patient could not identify all
quadrants, record the identified quadrants accordingly.
 Steps
10. If the patient still could not identify the direction
where the illuminating penlight is coming from, illuminate
the light directly on the patient's eye and ask the patient
if he or she can identify is there is presence of light. If
the patient can identify if there is presence of light,
record: "Light perception/LP with Good Projection” – Why?
Bec. It is a function of retina. Otherwise, "no light
perception/NLP".
 Steps
11. Repeat steps 3 to 10 on the opposite eye.
12. Record as follows, in feet and corresponding metric equivalent:

Figure 1. Recording Distance VA.

Uncorrected visual acuity is measured w/o glasses. Corrected acuity
means that these aids were worn. BCVA (Best-corrected Visual
Acuity) - best distance vision with eyeglasses or contact lenses;
UCVA (Uncorrected Visual Acuity) - Px can have 20/400 on the right
eye while 20/100 on the left eye
 Recording your snellen’s findings:
● Perfect score/normal: 20/20 (smallest letter can
be read)
● Can read 4th line completely: 20/50
● Can read more than half or half, record how many
were missed. (ex: 3 out of 5 letters = 20/40 -2)
○ “negative/ -” means missed/skipped letters
● Can read less than half, record how many were able
to read/see. (ex: 2 out of 5 letters = 20/50 +2)
○ “positive/ +” means not missed/ not skipped letters
 Recording your snellen’s findings:
● Legally blind: 20/200 & 20/400 (biggest letter can be
read)
● Visual acuity is scored as a fraction (eg, “20/40”).
The first number represents the testing distance
between the chart and the patient, and the second
number represents the smallest row of letters that the
patient’s eye can read. Hence, normal vision is 20/20,
and 20/60 acuity indicates that the patient’s eye can
only read from 20 ft letters large enough for a normal
eye to read from 60 ft.
 Pinhole va

• If the Px needs glasses or if his or her glasses are

unavailable, the corrected acuity can be estimated by
testing vision through a “pinhole”.
• Differences in acuity can often be due to refractive
error/ refractive blur caused by multiple misfocused
rays entering through the pupil & reaching the retina.
o Refractive Errors: Myopia/ Nearsightedness,
Hyperopia/ Farsightedness, Astigmatism
 Pinhole va
• Improvement of the Px’s vision using a pinhole would imply
that he or she probably has an error of refraction
o Viewing the Snellen chart through a placard of multiple
tiny pinhole-sized openings prevent most of the misfocused
rays from entering the eye. Only a few centrally aligned
focused rays will reach the retina, resulting in a sharper
image. In this manner, the patient may be able to read within
one or two lines of what would be possible if proper
corrective glasses were being used.
• In infants and toddlers, examiner should be alert to other
signs withdrawal or change in facial expression or sudden
movement in response to light w/c indicate the presence of
vision.
 steps
1. Position the patient and test the poorer eye first.
2. Ask the patient to hold the pinhole in front of the eye
that is to be tested.
3. Instruct the patient to look at the distance chart through
the single pinhole
4. Instruct the patient to use small hand or eye movements to
align the pinhole to resolve the sharpest image on the chart.
5. Have the patient read the line with the smallest letters
that are legible as determined on the previous vision test
without the use of a pinhole.
 steps
6. Record the Snellen acuity obtained and precede with the
abbreviation.

7. There is no need to have the patient come nearer during a

pinhole test. If Px could not read the chart, record as NIPH
- not improved on pinhole (think of Cataracts or Corneal
Scar)
 steps

Figure 2. Recording Pinhole (left) and Near VA (left).

Px’s 20/100 right eye is improve on two lines draw an arrow to 20/60.
(Improvement in two lines – Px might have Error of Refraction)
 Near vision testing
• Hold Jaeger Chart (convergence) at
12-14 inches or 35 cm in a
well-lighted room
• Test the worse eye first then the
good eye, then check each eye
individually with corrective lenses;
If the patient normally wears glasses
for reading, he or she should wear
them during testing.
 Near vision testing
● Sometimes done when distance testing is
difficult (at bedside)
● Unlike distance vision testing, near vision is
tested with both eyes open
● Since letter size designations and test
distances vary, both size and distance should
be recorded
○ ex. J5 at 14 inches, 6 pt at 35 cm
● If a standard near vision card is not
available, any printed material such as a
telephone book or newspaper may be substituted
 Steps
1. Check near vision with and without correction.
2. With the patient wearing the habitual corrective lens
for near and the near card evenly illuminated, instruct
the patient to hold the test card at the distance
specified on the card (usually 14 inches).
3. Examine the poorer eye or the eye in complaint.
4. Ask the patient to say each letter or read each word on
the line of smallest characters that are legible on the
card.
5. Record the acuity value for each eye separately in the
patient's chart.
 Steps
6. Repeat the procedure with the other eye
7. Repeat the procedure with both eyes viewing the test
card
8. Record the binocular acuity achieved.
9. If the patient could not read the largest optotype,
place "unable to read Jaeger chart"
Thank you!